We Have Happy Pills, Anxiety Drugs, and Therapists Galore: So Why Are We More Stressed and Depressed Than Ever?

More of us than ever are discontented and not experiencing optimum
emotional well-being. Why is the vast enterprise of professional mental
health unable to help us feel better?

An alternative to the old talking cure is expanding the knowledge base
of psychotherapy as we recognize the role that exercise, nutrition,
spirituality, mind-body approaches, and lifestyle can play in enhancing
our clinical effectiveness. Epidemic depression is occurring at a time
when the field of mental health appears very robust. There are more
mental health professionals treating more people than ever before in
history: psychiatrists, clinical psychologists, licensed social workers,
counselors, and therapists of all kinds. We have a powerful
"therapeutic arsenal" of drugs to make us happier, calmer, and saner.
When I leaf through the pharmaceutical ads that take up so much space in
psychiatric journals, I get the feeling that we should all be in great
emotional health. Depression and anxiety should be as fully conquered as
smallpox and polio. But more of us than ever are discontented and not
experiencing optimum emotional well-being. What is wrong with this
picture? Why is the vast enterprise of professional mental health unable
to help us feel better?

I want you to consider the possibility that the basic assumptions of
mainstream psychiatric medicine are obsolete and no longer serve us
well. Those assumptions constitute the biomedical model of mental health
and dominate the whole field.

In 1977, the journal Science published a
provocative article titled "The Need for a New Medical Model: A
Challenge for Biomedicine." I consider it a landmark in medical
philosophy and the intellectual foundation of today's integrative
medicine. The author, George L. Engel, M.D., was a professor of
psychiatry at the University of Rochester (New York) School of Medicine.
Determined to overcome the limiting influence of Cartesian dualism,
which assigns mind and body to separate realms, Engel envisioned medical
students of the future learning that health and illness result from an
interaction of biological, psychological, social, and behavioral
factors, not from biological factors alone. He fathered the field of
psychosomatic medicine and devoted much of his career to broadening our
understanding of disease. He was particularly interested in mental
health.

George Engel died in 1999 with his vision largely unrealized. In fact,
the field of psychosomatic medicine ran out of steam sometime before his
death and was never able to challenge the ascendancy of biological
medicine.

"Biology Explains All" was in full swing when I was a student at Harvard
Medical School in the late 1960s. At that time, I was taught that just
four diseases were psychosomatic: peptic ulcer, rheumatoid arthritis,
bronchial asthma, and ulcerative colitis. Four out of the entire catalog
of diseases is not a lot, but at least for those four, doctors conceded
that mental/emotional factors played a role. Peptic ulcer was knocked
off the list in the early 1980s when a bacterial infection (Helicobacter pylori)
was identified as the "real" cause of ulcers, now treatable with
antibiotics. Investigation of biological factors associated with the
three remaining conditions has led to more powerful drug treatments for
them and greatly lessened interest in attending to any psychological,
social, or behavioral factors that might be involved. Rheumatologists
today, for example, are most enthusiastic about a new class of
immunosuppressive drugs called TNF-α blockers, which often appear to put
rheumatoid arthritis and ulcerative colitis into full remission. Never
mind that these drugs can be highly toxic and are very expensive; once
doctors prescribe them for these conditions, they no longer see the
point of addressing emotional or lifestyle factors of the patients who
have them.

Although George Engel's efforts in psychosomatic medicine were ahead of
their time, their relevance today is great, and I advise all health
professionals, especially mental health professionals, to read his 1977
paper in Science. I will summarize his "challenge for
biomedicine" here, because it exposes the great limitations of the
conceptual model that now dominates medicine in general and psychiatric
medicine in particular. That model often fails to help doctors maintain
and heal our physical bodies, and it has greatly hindered our
understanding of and ability to manage the epidemic of depression and
other mood disorders that plague our society. It does not point the way
to contentment, comfort, serenity, and resilience, nor does it show us
how to attain optimum emotional well-being.

Ad

Models are belief systems - sets of assumptions and explanations we
construct to make sense of our experience. In Engel's words, "The more
socially disruptive or individually upsetting the phenomenon, the more
pressing the need of humans to devise explanatory systems." Disease is a
very upsetting phenomenon, and humans throughout history have come up
with a variety of belief systems to explain it, from the wrath of the
gods to possession by spirits to disharmony with the forces of nature.
The dominant model of disease in our time is biomedical, built on a
foundation of molecular biology. As Engel explains,

"It assumes disease to be fully accounted for by deviations from the
norm of measurable biological (somatic) variables. It leaves no room
within its framework for the social, psychological, and behavioral
dimensions of illness. The biomedical model not only requires that
disease be dealt with as an entity independent of social behavior, it
also demands that behavioral aberrations be explained on the basis of
disordered somatic (biochemical or neurophysiological) processes. Thus
the biomedical model embraces both reductionism, the philosophic view
that complex phenomena are ultimately derived from a single primary
principle, and mind-body dualism."

Engel goes on to say, "The biomedical model has . . . become a cultural
imperative, its limitations easily overlooked. In brief, it has now
acquired the status of a dogma. . . . Biological dogma requires that all
disease, including 'mental' disease, be conceptualized in terms of
derangement of underlying physical mechanisms." He proposed an
alternative: a biopsychosocial model of health and illness.

There is no question that over the past century, biomedicine has
advanced our knowledge of human biology, but the real test of a
scientific model - the measure of its superiority to an alternative
belief system - is whether or not it increases our ability to describe,
predict, and control natural phenomena. In my books about health and
healing, I have written a great deal about how strict application of the
biomedical model has actually made it harder for us to understand and
manage common diseases. For instance, I have pointed out that it fails
to account for the fact that many people infected with H. pylori
never develop peptic ulcers or have any symptoms at all. They coexist
with it in a balanced way. Clearly, factors other than the simple
presence of that germ play a role in peptic ulcer disease, including the
strength or weakness of host defenses, of an individual's resistance.
One of those defenses is stomach acid, whose production is influenced by
the autonomic (involuntary) nervous system and through it by emotions.
In the fight-or-flight response, the sympathetic division of the
autonomic nervous system shuts down gastrointestinal function, which is
unnecessary in an emergency, in order to divert energy and blood flow to
muscles. That includes turning off the production of acid in the stomach. In
chronic anxiety and stress, the sympathetic nerves are constantly
overactive, and therefore there is constantly less acid in the stomach
to keep potentially invasive germs from causing tissue damage. To say that H. pylori infection is strongly correlated with peptic ulcer disease is accurate. To say that it is the sole cause of ulcers ignores the complexity of causation and the possible influence of emotions.

In 1980, the American Psychiatric Association radically revised the Diagnostic and Statistical Manual - III (DSM-III)
to be in accord with the biomedical model. As a consequence, the role
of psychiatrists went from being facilitators of insight in patients to
being dispensers of drugs to modify brain chemistry. Although some
psychiatrists still rely on talk therapy, of all medical specialties,
the profession as a whole is the most dominated and, to my mind, hobbled
by blind faith in biomedicine. Psychiatrists were easily seduced
because of a collective inferiority complex with regard to their place
in the medical hierarchy. Still referred to as witch doctors and shrinks
(from headshrinkers), they themselves have a history of questioning
whether they are real doctors and whether they need the same basic
medical training as cardiologists and surgeons. With the spectacular
rise of biomedicine, their discomfort increased, and, not wanting to be
left behind, they looked for ways to be even more biologically correct
than their colleagues in other specialties. They saw their ticket to
acceptance in the new and rapidly developing field of psychopharmacology
- the study of the effect of drugs on mental and emotional disorders.

In 1921, Otto Loewi (1873 - 1961), a German pharmacologist, demonstrated
that nerve cells (neurons) communicate by releasing chemicals. Prior to
that time, neuroscientists thought nervous communication was
electrical. Among the many important breakthroughs that followed from
Loewi's work were the identification of neurotransmitters and the
discovery of receptors on cell surfaces that bind them.
Neurotransmitters are chemicals made within the body, stored in tiny
sacs clustered within a neuron and released into the synapse, the gap
between the neuron and a target cell, which might be another neuron (the
postsynaptic neuron) or a muscle or glandular cell. The released
molecules then bind to receptors - specialized proteins on the surface
membrane of the target cell - causing changes in that cell, making it
more or less likely to produce an electrical signal (in the case of a
neuron), to contract (in the case of a muscle), or to secrete a hormone
(in the case of a glandular cell). Later, the neurotransmitters can
separate from their receptors and be taken up by presynaptic cells for
reuse or be broken down by enzymes into inactive metabolites.
Neuroscientists have now compiled long lists of neurotransmitters,
described their actions, and identified many types and subtypes of
receptors.

Three of the most studied neurotransmitters are norepinephrine,
dopamine, and serotonin, all very relevant to the subject at hand
because they influence our moods and emotions. For example, dopamine is
involved in what is known as the reward system of the brain; drugs that
affect it can alter our experience of pleasure. Cocaine is such a drug.
It blocks reuptake of dopamine back into the presynaptic neuron,
effectively increasing its action at the synapse to produce an intense
pleasurable response. With prolonged use of cocaine, postsynaptic
neurons become less responsive to dopamine, leading to depression and
dependence on the drug to relieve it. The dopamine hypothesis of
schizophrenia attributes psychosis to overactivity of this
neurotransmitter. Norepinephrine regulates both reward and arousal.
Disturbances in that neurotransmitter system are associated with anxiety
disorders. And serotonin affects our moods and sleep.

The most widely used psychiatric drugs today influence the production
and effects of these major neurotransmitters. Psychopharmacologists made
their first big breakthrough in the 1950s from work with
antihistamines, used to quell allergic symptoms. Although antihistamines
are best known for blocking the effects of the compound responsible for
certain immune responses, they also affect the brain, often making
people groggy, sleepy, and depressed. By tinkering with these molecules,
chemists produced a new class of psychoactive drugs - the
phenothiazines - that blocked dopamine transmission. Thorazine and other
phenothiazines were successfully marketed as major tranquilizers and
antipsychotics and quickly revolutionized the treatment of
schizophrenia. Psychiatrists hailed them as magical compounds that cured
psychosis, while critics argued that they simply made psychotic people
groggy, sedated, and easier to manage, even as outpatients. Energized by
this achievement, psychopharmacologists then turned their attention to
depression. Over the past sixty years, they have come up with a number
of drugs to treat it.

The efforts of psychopharmacologists give us an opportunity to evaluate
the usefulness of the biomedical model in psychiatry. In practice,
psychiatric medicine today is synonymous with psychopharmacology. The
credo of that field is "There is no twisted thought without a twisted
molecule." (The words of the American neurophysiologist Ralph Gerard,
1900 - 1974). The biomedical model explains depression as the result of a
chemical imbalance in the brain, specifically of neurotransmitters
affecting our moods. How well does that explanation enable us to
describe, predict, and control depressive illness? In other words, just
how effective are the antidepressant drugs that psychopharmacologists
have developed, that the big pharmaceutical companies sell such
quantities of, and that so many people today take? The answer, I'm
afraid, is not very.

The first antidepressant drug was discovered serendipitously in 1952.
Iproniazid, an antimicrobial agent being studied as a possible treatment
for tuberculosis, was found to affect mood, making even terminally ill
patients cheerful and optimistic. Investigation of a possible mechanism
for this unexpected psychoactivity revealed that the drug blocked
enzymatic breakdown of all three major neurotransmitters:
norepinephrine, dopamine, and serotonin. Pharmaceutical chemists then
looked for other drugs with this action and soon after produced a
different class of antidepressant drugs by modifying the phenothiazine
tranquilizers. These became known as tricyclic antidepressants, of which
amitriptyline was the prototype; Merck pharmaceutical company gave it
the brand name Elavil. In 1961, the FDA approved Elavil for the
treatment of major depression, and it quickly became a bestselling drug.
The tricyclics appeared to work by blocking presynaptic reuptake of
norepinephrine and serotonin without affecting dopamine.

Because all of the early antidepressants had unpleasant side effects and
serious potential interactions with other drugs and medications,
pharmaceutical chemists continued their search for better ones with more
specific action. But what specific action should it be? Some thought
deficiency of norepinephrine was the biochemical cause of depression.
Others argued for a serotonin hypothesis of depression and looked for
compounds to prevent its breakdown or reuptake. The proponents of the
serotonin hypothesis would win the day; their big discovery came in the
1970s, again, interestingly enough, as a result of work with an
antihistamine.

Very likely you have taken Benadryl (diphenhydramine) at some point in
your life. It is one of the oldest and most widely used antihistamines,
the first such drug to be approved by the FDA for prescription use, in
1946. Benadryl is so sedating that it is now sold over the counter as a
sleep aid. In the 1960s, this tried-and-true drug was found to have an
action independent of its effect on histamine: it selectively inhibited
the reuptake of serotonin. By modifying this molecule, scientists at Eli
Lilly and Company in the 1970s came up with the first safe and
effective selective serotonin reuptake inhibitor, fluoxetine, much
better known by its brand name Prozac. The rest is history. Today the
accepted biomedical explanation of depression is that it results from a
deficiency of serotonin at synapses in key areas of the brain;
therefore, boosting the activity of this neurotransmitter with drugs
that block its reuptake will treat or cure the problem.

It's a good bet that thirty years ago, not one American in a thousand
had heard of this neurotransmitter - or any neurotransmitters, for that
matter. Today, when you Google serotonin, about 11 million results
appear, and Amazon sells nearly three thousand books with the word in
the title (including The Serotonin Solution: The Potent Brain Chemical That Can Help You Stop Bingeing, Lose Weight, and Feel Great).
"Serotonin" is the name of a professional wrestling team and an album
by the British rockers The Mystery Jets. You can even proclaim your
autumn blues to friends by way of a greeting card that reads, "The
leaves and my serotonin levels are falling." A once-obscure
neurochemical has become pop-culture currency, and increasing levels of
this feel-good compound has turned into a public obsession.

None of this just happened on its own. In order to sell antidepressant
medications, drug manufacturers launched a relentless worldwide
marketing and public-relations campaign promoting serotonin as the
distilled biochemical essence of happiness. The message was that
selective serotonin reuptake inhibitors - SSRIs - increase synaptic
levels of serotonin in the brain by slowing its rate of reabsorption by
presynaptic neurons, ending depression. Psychiatrists and other
physicians got the technical version of this message, while consumers
got a simplified one, often reduced to the rallying cry "Boost
serotonin!"

The only problem is that it probably isn't true.

Like the dopamine hypothesis of schizophrenia and other attempts to
attribute complex mental phenomena to simplistic biochemical causes, the
serotonin hypothesis of depression is shaky at best. Several studies
have established that lowering serotonin levels does not negatively
impact mood. In fact, a new pharmaceutical known as tianeptine - sold in
France and other European countries under the trade name Coaxil - has
been shown to be as effective as Prozac. Tianeptine works by lowering
synaptic serotonin. As psychology professor Irving Kirsch of the
University of Hull in England told Newsweek,

"If depression can be equally affected by drugs that increase serotonin
and by drugs that decrease it, it's hard to imagine how the benefits
can be due to their chemical activity."

It is, indeed, especially as evidence accumulates that, in most cases,
SSRIs work no better than placebos to boost mood. The first such
analysis, published in 1998, looked at thirty-eight
manufacturer-sponsored studies that included more than three thousand
depressed patients. It found negligible differences in improvement
between those on the drugs and those on dummy pills. At least 75 percent
of the benefit from this class of antidepressants seemed to be a
placebo effect. This finding has since been confirmed by other research.

To say that biomedically minded physicians have been reluctant to accept
this finding or modify their prescribing habits as a result would be a
great understatement. Both professional and popular media have tried to
play down the significance of this new research and in some cases have
misreported the findings. In April 2002, the Journal of the American Medical Association
(JAMA) published the results of a large randomized controlled study
sponsored by the National Institutes of Health to evaluate a popular
herbal treatment for depression, St. John's wort (Hypericum perforatum).
Its effect was compared with that of the widely prescribed SSRI Zoloft
(sertraline) and a placebo in 340 patients with major depressive
disorder. The conclusion that made front-page news around the world was
that St. John's wort worked no better than the placebo at relieving
depression. Television news shows featured reporters in health-food
stores pointing to St. John's wort products and advising consumers not
to waste their money on natural remedies whose supposed benefits were
nothing more than old wives' tales.

Never mind that St. John's wort is not indicated for the treatment of
major depression, making the point of the study questionable. The
finding from this well-designed trial that should have made front-page
news was that Zoloft also worked no better than the placebo. In fact,
the placebo treatment was actually more effective in these very
depressed patients than either Zoloft or St. John's wort!

Irving Kirsch summarized the growing body of evidence against SSRIs in his 2010 book, The Emperor's New Drugs: Exploding the Antidepressant Myth,
which I recommend. In response, proponents of the drugs and the
serotonin hypothesis retreated to a more defensible position: SSRIs may
owe much of their apparent benefit to patients' belief in them, they
admit, but they still have a real biochemical effect that makes them
useful in the treatment of severe depression. Unfortunately for those
proponents, the most recent analysis, published in the January 6, 2010,
issue of JAMA, rates the real biochemical effect of SSRIs as
nonexistent to negligible even in most cases of severe depression. Only
in patients with very severe symptoms can researchers detect a
statistically significant drug benefit compared with that of a placebo.
About 13 percent of people with depression have very severe symptoms.
One of the authors of the JAMA paper, Steven D. Hollon, Ph.D.,
of Vanderbilt University, has said, "Most people [with depression] don't
need an active drug. For a lot of folks, you're going to do as well on a
sugar pill or on conversations with your physicians as you will on
medication. It doesn't matter what you do; it's just that you're doing
something."

Comment/Related: Read the following articles written by Dr. Irving Kirsch for more 'data' on the placebo effect:

I would argue that the dismal performance of Prozac, Zoloft, Paxil,
and other antidepressant drugs relative to placebos not only leaves the
serotonin hypothesis of depression without a leg to stand on but also
exposes the failure of the biomedical model to further our understanding
of and ability to manage emotional disorders. I firmly believe that the
nature of depression will never be revealed solely in studies of brain
biochemistry that are isolated from the rest of human experience. Like
coronary heart disease, depression is a multifactorial health problem,
rooted in complex interactions of biological, psychological, and social
variables, best understood and managed through a broader biopsychosocial
model of the sort proposed by George Engel.

Loneliness, for example, is a powerful predictor of depression. Numerous
studies show that people with few intimate social contacts are more
likely to be depressed than those who enjoy a rich network of friends
and family. Reductionists might argue that being part of a social group
boosts serotonin, but I am confident that there is something in a
successful social life that transcends any effect on brain biochemistry,
at least insofar as we currently understand that biochemistry. In other
words, a happy family life probably raises serotonin in some people,
lowers it in others, and leaves it unaffected in still others. Yet it
makes them all more comfortable, serene, and relatively immune to mood
disorders through a body-mind-social interaction that can't be reduced
to its constituent parts.

The New Model

I have written about possible causes of epidemic depression in our society, among them such lifestyle factors as diets high in processed foods,
lack of physical activity, social isolation resulting from affluence,
and altered brain activity from information overload. In its narrow
focus on molecular biology, the biomedical model fails to capture any of
this, and practitioners under its spell cannot give depressed patients
the advice they need to address the complex causes of their problems.
All they can do is dispense drugs that for the majority of patients
might as well be sugar pills.

In an effort to give mental health professionals more and better
options, I convened the first national conference on integrative mental
health in March 2010. Together with Victoria Maizes, M.D., executive
director of the Arizona Center for Integrative Medicine, I invited
psychiatrists, psychologists, social workers, and other health
professionals to attend a three-day event in Phoenix to "learn how to
treat their patients within a new paradigm of integrative mental health
care that utilizes scientifically proven alternative methods in
combination with drugs and traditional therapy to address patients'
physical, psychological, and spiritual needs." The use of the word
spiritual here is significant; it expands George Engel's concept to
include yet another dimension of human life, one often overlooked in
medicine. Adding it creates a biopsychosocialspiritual model. For
convenience, I prefer the term integrative to describe this new way of
thinking about health and illness in general and mental health in
particular.

Dr. Maizes and I invited leading practitioners and researchers to share
their experience and findings with attendees. We planned for an audience
of three hundred, but, in a time of great economic recession, the
conference sold out six weeks in advance with a total of seven hundred
registrants. If we had had a larger venue, we could have doubled that
number, so great was the interest in the topic - evidence, I think, that
professionals are even more fed up than patients with the dead end that
the drug-only approach represents.

On the closing day of the conference, I spoke about the failure of the
biomedical model and the great advantages of the new integrative model
of mental health. I quoted Albert Einstein on the subject of conceptual
models:

"Creating a new theory is not like destroying an old barn and erecting a
skyscraper in its place. It is rather like climbing a mountain, gaining
new and wider views, discovering unexpected connections between our
starting point and its rich environment. But the point from which we
started still exists and can be seen, although it appears smaller and
forms a tiny part of our broad view gained by the mastery of the
obstacles on our adventurous way up."

The new integrative model of mental health does not ignore brain
biochemistry. It takes into account correlations between imbalances in
neurotransmitters and mood disorders. Nor does it reject
psychopharmacology. Integrative treatment plans for depression,
particularly for severe depression, may well include medication, but my
colleagues and I prefer to try other methods first and to use
antidepressant drugs for short-term management of crises rather than
rely on them as long-term solutions. One of the invited speakers, a
noted expert on psychopharmacology, gave an optimistic presentation on
psychiatric drugs of the future, drugs that will have more specific,
better-targeted actions. People listened to his lecture with interest
but showed much greater enthusiasm for talks on the critical importance
of dietary omega-3 fatty acids to optimum emotional health and the
latest neuroscientific evidence for the benefits of meditation, among
others.

To say that the psychiatrists, psychologists, and other mental health
professionals in attendance appreciated this larger perspective fails to
convey their excitement. One told me that she had been waiting years
for such a conference. Another said he would take the information he
received and use it to change standards of practice in a large group of
mental health care facilities in his state. Many expressed interest in
seeking formal training in integrative mental health, training that I
and my colleagues at the University of Arizona hope to provide.

Presentations that particularly interested me concerned neuroplasticity,
the potential of the brain and nervous system to change and adapt. The
speakers were neuroscientists influenced by Buddhist psychology and the
teachings of the Dalai Lama. Using such new techniques as PET scans and
functional MRIs, which make it possible to visualize living brains, they
have been able to show that individuals trained in meditation have
different brain activity from those without such training, and they
respond differently to situations that would cause most of us to lose
our emotional equilibrium. The broader implication of this research is
that changes in the mind can cause changes in both the function and
structure of the brain, a fact that cannot be explained by the
biomedical model and that suggests many more options for taking charge
of our emotional well-being.

In retrospect, seeing human beings as nothing more than the sum of
biochemical interactions was probably a necessary stage of medical
evolution. Medical systems of the past lacked the technology to study
the biological underpinnings of human health with rigor and precision.
Now we have that technology, and we've used it well to gain invaluable
insights about our physical bodies. But it is impossible to restore or
promote human health unless we begin with a complete definition of a
human being. An incomplete definition will always result in incomplete
diagnoses and less-than-optimal treatments.

So now is the time to ascend the mountain and see the biomedical model
as one part of our broadening view. Our health or lack of it is the
result of biochemical interactions and genetics, dietary choices,
exercise patterns, sleep habits, hopes, fears, families, friends, jobs,
hobbies, cultures, ecosystems, and more. Chemical imbalances in the
brain may well correlate with depression, anxiety, and other emotional
states but the arrows of cause and effect can point in both directions.
Optimizing emotional wellness, by improving attention, changing
destructive patterns of thinking, and finding contentment within, can
also optimize brain chemistry, correcting any deficiencies in
neurotransmitters.

George Engel showed us the path upward more than thirty years ago. Now, I am happy to say, we are starting to follow it.

About the author

Andrew Weil, M.D., is a world-renowned leader and pioneer in the
field of integrative medicine, a healing oriented approach to health
care which encompasses body, mind, and spirit.

Intellectual Center Reviews

Intellectual Center provides Independent News in blog format to assist other activists, teachers, and elders with alternative news, information on social issues, and research material.

FAIR USE NOTICE: Intellectual Center (Website) may post copyrighted material not specifically authorized in accordance with Section 107 of U.S. Copyright Law allowing purposes associating learning processes. Please be advised if you intend to use such copyrighted material for personal reasons beyond "fair use," considerations, please obtain permission from the copyright owner. Learning processes encompass a vast array of issues of concern and would not be restrictive, it would offer critique and extended scholarly research.

Website may display third party authors/advertising which may not represent the views or opinions of Website or contributors. Advertisements are not endorsed as such and are intended as alternative ways to support the work at Website.